Pelvic floor disorders Flashcards Preview

Obstetrics and Gynaecology > Pelvic floor disorders > Flashcards

Flashcards in Pelvic floor disorders Deck (14):
1

Define prolapse

1. Descent of pelvic organs due to weakness of the structures that normally hold in place

2

Endopelvic fascial ligaments

1. Pubocervical

2. Cardinal ligaments

3. Uterosacral ligaments

3

Etiology

1. Congenital weakness in endopelvic fascia

2. Acquired

a. Childbirth->Forceps, vacuum, ++birth weight, prolonged second stage b. Lifestyle->Obesity, chronic cough, constipation, heavy loads, ageing

4

Classification of genital prolapse

1. Dislocation of the urethra

Displaced downwards and backwards off the pubic

2. Cystocele

Herniation of bladder trigoe->weak vaginal/pubocervical fascia

Bladder pouch forms, residual urine, UTI

3. Uterine prolapse

Uterus and cervix

4. Enterocele

Pouch of douglas herniation

5. Rectocele

Prolapse of lower vaginal wall->rectum bulges into vagina

6. Perineal body

May be deficien/part of anal canal buldging into vagina

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5

Degress of cystocele

1. First degree: Cervix remains in upper vagina, >1 cm from hymen 2. Second degree: Cervix reaches down to vulva on straining, doesn't pass through it w/i 1cm hymen 3. Third degree: cervix/some of uterus prolapsing outside vaginal orifice

6

History in pelvic organ prolapse

1. Symptoms

a) Vaginal b) Urinay c) Bowel d) sexual

Lump in vagina

Dragging feeling

Bachache

Difficult intercourse

Bleeding/discharge/ulceration

UTI Incomplete bladder emptying

Manual defecation/urination

2. Risk factors

Vaginal birth

Operative

Pelvic surgery

Obesity

Constipation

Cough

Smoking

CT->history of hernias

7

Eamination

1. Empty bladder/bowel 2. Speculum 3. Strong valsalva 4. Anterior Urethra + bladder 5. Central w/ uterus, small bowel Uterine prolapse Vault prolapse 6. Posterior compartment Small bowel Rectum

8

Differential

Vaginal and periurethral cysts

Tumors

Diverticulum of urethra

Urethral caruncle

Mucosal prolapse 

9

Prevention

1. In childbirth

Careful Mx of labour

Discourage from pushing until fully dilated= ++strain on uterine supports'

Do not prolong second stage unduly

Carefully suture episiotomies in layers

Postnatal exercises

2. Lose weight

3. Treat underlying cause of cough

4. Smoking cessation

5. Treat constipation

10

Management

1. Pelvic floor exercises, watchful waiting

2. Treat UTI

3. Antispasmodics for urge incontinence and detrusor instability

4. Pessaries

Exchanged every 3-4 months

B/t posterior fornix and anterior vaginal wall

May cause ulceration, embed in wall, carcinoma

5. Vaginal surgery

Anterior and posterior colporrhaphy

Sling repair, transvaginal mesh repair

Need urodynamics prior to treatment

6. Uterine prolapse

Hysterectomy

Apex or paravaginal repair

11

Delancey classification

1. Level 1 (paramilleurian): The cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the bony sacrum. Uterine prolapse occurs when the cardinal-uterosacral ligament complex breaks or is attenuated.

Organ: Uterus, vault

Symptoms: Back pain, urinary obstruction, fullness/mass, UTI

Pathology: Uterine prolapse

Treatment: Transvaginal sacrospinous fixation/hysteropexy->attach to sacrospinous ligament

Laparoscopic sacrocolpopexy->Mesh fixed to ant and posterior vault stapled to sacral promontory

2. Level 2: The arcus tendineous fascia pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina 

Damage results in rectocele or cystocele (pubo-vesical-cervical fascia)

a) Anterior

Organ: Bladder: paravaginal fascia

Symptoms: obstruction

Pathology: cystocele

Treatment: Native tissue repair, Mesh repair (low recurrence, extrusion, protrusion)

Colporrhaphy

b) Posterior: Rectum

3. Level 3 (urogenital sinus, cloaca): The urogenital diaphragm and the perineal body provide support to the lower part of the vagina.

Damage results in deficient perineal body or urethrocele

a) Anterior: Urethra, periurethral fascia

Symptoms: Stress urinary incontinence

Pathology: Urethrohypomobility

Treatment: Transvaginal tape

b) Posterior: Perineum, peritoneum

Symptoms: Vaginal wind

Pathology: Deficient perineum

Treatment: Perinealplasty

12

Staging uterine prolapse

Stage 0: No prolapse

Stage I: The most distal portion of the prolapse is >1 cm above the level of the hymen

Stage II: The most distal portion of the prolapse is ≤1 cm proximal or distal to the hymen

Stage III: The most distal portion of the prolapse is >1 cm below the hymen but protrudes no further than 2 cm less than the total length of the vagina

Stage IV: Complete eversion of the vagina

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13

Degree of perineal tear

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14

Episiotomy

1. Incision in perineum

2. the perineum is incised with scissors or a scalpel as the infant’s head is crowning.

3. An incision is begun at the posterior fourchette and continued downward at an angle of at least 45° relative to the perineal body. The angle of the incision may approach 90° (perpendicular to the posterior fourchette) if the perineum is significantly stretched by the fetal head, so that upon relaxation of the perineum the angle will approach 45°. The incision can be performed on either side and is generally 3-4 cm in length.

4. anatomic structures involved in a mediolateral episiotomy include the vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, and perineal skin.